Release 4 5

This page is part of the FHIR Specification (v4.0.1: R4 (v5.0.0: R5 - Mixed Normative and STU ) ). This is the current published version in it's permanent home (it will always be available at this URL). The current version which supercedes this version is 5.0.0 . For a full list of available versions, see the Directory of published versions . Page versions: R5 R4B R4

Claimresponse-example-unsolicited-preauth.json

Example ClaimResponse/UR3503 (JSON)

Financial Management Work Group Maturity Level : N/A Standards Status : Informative Compartments : Patient , Practitioner

Raw JSON ( canonical form + also see JSON Format Specification )

Unsolicited Pre-Authorization for social Dental Services 

{
  "resourceType": "ClaimResponse",
  "id": "UR3503",
  "text": {
    "status": "generated",
    "div": "<div xmlns=\"http://www.w3.org/1999/xhtml\">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div>"

  "resourceType" : "ClaimResponse",
  "id" : "UR3503",
  "text" : {
    "status" : "generated",
    "div" : "<div xmlns=\"http://www.w3.org/1999/xhtml\">A sample unsolicited pre-authorization response which authorizes basic dental services to be performed for a patient.</div>"

  },
  "identifier": [
    {
      "system": "http://www.SocialBenefitsInc.com/fhir/ClaimResponse",
      "value": "UR3503"
    }
  ],
  "status": "active",
  "type": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/claim-type",
        "code": "oral"
      }
    ]

  "identifier" : [{
    "system" : "http://www.SocialBenefitsInc.com/fhir/ClaimResponse",
    "value" : "UR3503"
  }],
  "status" : "active",
  "type" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/claim-type",
      "code" : "oral"
    }]

  },
  "use": "preauthorization",
  "patient": {
    "reference": "Patient/1"

  "use" : "preauthorization",
  "patient" : {
    "reference" : "Patient/1"

  },
  "created": "2014-08-16",
  "insurer": {
    "identifier": {
      "system": "http://www.jurisdiction.org/insurers",
      "value": "444123"

  "created" : "2014-08-16",
  "insurer" : {
    "identifier" : {
      "system" : "http://www.jurisdiction.org/insurers",
      "value" : "444123"

    }
  },
  "requestor": {
    "reference": "Organization/1"

  "requestor" : {
    "reference" : "Organization/1"

  },
  "outcome": "complete",
  "disposition": "The enclosed services are authorized for your provision within 30 days of this notice.",
  "preAuthRef": "18SS12345",
  "payeeType": {
    "coding": [
      {
        "system": "http://terminology.hl7.org/CodeSystem/payeetype",
        "code": "provider"
      }
    ]

  "outcome" : "complete",
  "disposition" : "The enclosed services are authorized for your provision within 30 days of this notice.",
  "preAuthRef" : "18SS12345",
  "payeeType" : {
    "coding" : [{
      "system" : "http://terminology.hl7.org/CodeSystem/payeetype",
      "code" : "provider"
    }]

  },
  "addItem": [

  "addItem" : [{
    "itemSequence" : [1],
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/oralservicecodes",
        "code" : "1101"
      }]
    },
    "modifier" : [{
      "coding" : [{
        "system" : "http://example.org/fhir/modifiers",
        "code" : "x",
        "display" : "None"
      }]
    }],
    "net" : {
      "value" : 250.00,
      "currency" : "USD"
    },
    "noteNumber" : [101],
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "code" : "eligible"
        }]
      },
      "amount" : {
        "value" : 250.00,
        "currency" : "USD"
      }
    },

    {
      "itemSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "system": "http://example.org/fhir/oralservicecodes",
            "code": "1101"
          }
        ]

      "category" : {
        "coding" : [{
          "code" : "copay"
        }]

      },
      "modifier": [
        {
          "coding": [
            {
              "system": "http://example.org/fhir/modifiers",
              "code": "x",
              "display": "None"
            }
          ]
        }
      ],
      "net": {
        "value": 250.00,
        "currency": "USD"

      "amount" : {
        "value" : 10.00,
        "currency" : "USD"
      }
    },
    {
      "category" : {
        "coding" : [{
          "code" : "eligpercent"
        }]

      },
      "noteNumber": [
        101
      ],
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 250.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "copay"
              }
            ]
          },
          "amount": {
            "value": 10.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 100.00
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 240.00,
            "currency": "USD"
          }
        }
      ]

      "quantity" : {
        "value" : 100.00
      }

    },
    {
      "itemSequence": [
        1
      ],
      "productOrService": {
        "coding": [
          {
            "system": "http://example.org/fhir/oralservicecodes",
            "code": "2101",
            "display": "Radiograph, series (12)"
          }
        ]

      "category" : {
        "coding" : [{
          "code" : "benefit"
        }]

      },
      "net": {
        "value": 800.00,
        "currency": "USD"

      "amount" : {
        "value" : 240.00,
        "currency" : "USD"
      }
    }]
  },
  {
    "itemSequence" : [1],
    "productOrService" : {
      "coding" : [{
        "system" : "http://example.org/fhir/oralservicecodes",
        "code" : "2101",
        "display" : "Radiograph, series (12)"
      }]
    },
    "net" : {
      "value" : 800.00,
      "currency" : "USD"
    },
    "adjudication" : [{
      "category" : {
        "coding" : [{
          "code" : "eligible"
        }]

      },
      "adjudication": [
        {
          "category": {
            "coding": [
              {
                "code": "eligible"
              }
            ]
          },
          "amount": {
            "value": 800.00,
            "currency": "USD"
          }
        },
        {
          "category": {
            "coding": [
              {
                "code": "eligpercent"
              }
            ]
          },
          "value": 100.00
        },
        {
          "category": {
            "coding": [
              {
                "code": "benefit"
              }
            ]
          },
          "amount": {
            "value": 800.00,
            "currency": "USD"
          }
        }
      ]
    }
  ],
  "total": [

      "amount" : {
        "value" : 800.00,
        "currency" : "USD"
      }
    },

    {
      "category": {
        "coding": [
          {
            "code": "submitted"
          }
        ]

      "category" : {
        "coding" : [{
          "code" : "eligpercent"
        }]

      },
      "amount": {
        "value": 1050.00,
        "currency": "USD"

      "quantity" : {
        "value" : 100.00

      }
    },
    {
      "category": {
        "coding": [
          {
            "code": "benefit"
          }
        ]

      "category" : {
        "coding" : [{
          "code" : "benefit"
        }]

      },
      "amount": {
        "value": 1040.00,
        "currency": "USD"

      "amount" : {
        "value" : 800.00,
        "currency" : "USD"

      }
    }]
  }],
  "total" : [{
    "category" : {
      "coding" : [{
        "code" : "submitted"
      }]
    },
    "amount" : {
      "value" : 1050.00,
      "currency" : "USD"

    }
  ],
  "processNote": [
    {
      "number": 101,
      "type": "print",
      "text": "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.",
      "language": {
        "coding": [
          {
            "system": "urn:ietf:bcp:47",
            "code": "en-CA"
          }
        ]
      }

  },
  {
    "category" : {
      "coding" : [{
        "code" : "benefit"
      }]
    },
    "amount" : {
      "value" : 1040.00,
      "currency" : "USD"

    }
  ],
  "insurance": [
    {
      "sequence": 1,
      "focal": true,
      "coverage": {
        "reference": "Coverage/9876B1"
      }

  }],
  "processNote" : [{
    "number" : 101,
    "type" : {
      "coding" : [{
        "system" : "http://hl7.org/fhir/note-type",
        "code" : "print"
      }]
    },
    "text" : "Please submit a Pre-Authorization request if a more extensive examination or urgent services are required.",
    "language" : {
      "coding" : [{
        "system" : "urn:ietf:bcp:47",
        "code" : "en-CA"
      }]

    }
  ]

  }],
  "insurance" : [{
    "sequence" : 1,
    "focal" : true,
    "coverage" : {
      "reference" : "Coverage/9876B1"
    }
  }]

}

Usage note: every effort has been made to ensure that the examples are correct and useful, but they are not a normative part of the specification.